Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident was observed lying on their back in bed, which was positioned at its highest and flattest setting, with a hoyer sling underneath and a foley catheter bag resting on their right thigh. No staff were present in the room or nearby hallway at the time of observation. The resident reported that their nursing assistant had left to retrieve something and that they had been left in this position for five minutes, expressing feelings of helplessness. During this period, another staff member entered the room only to inform the resident about upcoming activities and then left without addressing the resident's position or the placement of the catheter bag. The assigned GNA later returned, at which point the surveyor shared concerns about the resident's safety. The GNA then adjusted the catheter bag to hang below the bladder and lowered the bed before leaving the room again. The incident was acknowledged by both the LPN and the Unit Manager, RN, who confirmed understanding of the concerns. The resident's care plan indicated complete dependence on staff for meeting their needs due to physical limitations. The sequence of events demonstrated a failure to ensure the resident was free from accident hazards and to provide adequate supervision to prevent accidents.